title: The association between prehospital care and in-hospital treatment decisions in acute stroke: a cohort study.
abstract: BACKGROUND
  Hospital prealerting in acute stroke improves the timeliness of subsequent treatment, but little is known about the impact of prehospital assessments on in-hospital care.
  
  
  OBJECTIVE
  Examine the association between prehospital assessments and notification by emergency medical service staff on the subsequent acute stroke care pathway.
  
  
  METHODS
  This was a cohort study of linked patient medical records. Consenting patients with a diagnosis of stroke were recruited from two urban hospitals. Data from patient medical records were extracted and entered into a Cox regression analysis to investigate the association between time to CT request and recording of onset time, stroke recognition (using the Face Arm Speech Test (FAST)) and sending of a prealert message.
  
  
  RESULTS
  151 patients (aged 71±15 years) travelled to hospital via ambulance and were eligible for this analysis. Time of symptom onset was recorded in 61 (40%) cases, the FAST test was positive in 114 (75%) and a prealert message was sent in 65 (44%). Following adjustment for confounding, patients who had time of onset recorded (HR 0.73, 95% CI 0.52 to 1.03), were FAST-positive (HR 0.54, 95% CI 0.37 to 0.80) or were prealerted (HR 0.26, 95% CI 0.18 to 0.38), were more likely to receive a timely CT request in hospital.
  
  
  CONCLUSIONS
  This study highlights the importance of hospital prealerting, accurate stroke recognition, and recording of onset time. Those not recognised with stroke in a prehospital setting appear to be excluded from the possibility of rapid treatment in hospital, even before they have been seen by a specialist.
authors.affiliation: Primary Care Clinical Sciences, NIHR School for Primary Care Research, University of Birmingham, Birmingham, West Midlands, UK Department of Primary Care Health Sciences, NIHR School for Primary Care Research, University of Oxford, Oxford, Oxfordshire, UK.
authors.forename: James P
authors.initials: JP
authors.lastname: Sheppard
authors.affiliation: Primary Care Clinical Sciences, NIHR School for Primary Care Research, University of Birmingham, Birmingham, West Midlands, UK.
authors.forename: Ruth M
authors.initials: RM
authors.lastname: Mellor
authors.affiliation: Primary Care Clinical Sciences, NIHR School for Primary Care Research, University of Birmingham, Birmingham, West Midlands, UK.
authors.forename: Sheila
authors.initials: S
authors.lastname: Greenfield
authors.affiliation: Primary Care Unit, University of Cambridge, Cambridge, Cambridgeshire, UK.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Mant
authors.affiliation: Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey UK.
authors.forename: Tom
authors.initials: T
authors.lastname: Quinn
authors.affiliation: Heart of England NHS Foundation Trust, Birmingham, West Midlands, UK.
authors.forename: David
authors.initials: D
authors.lastname: Sandler
authors.affiliation: University Hospitals Birmingham NHS Foundation Trust, Birmingham, West Midlands, UK.
authors.forename: Don
authors.initials: D
authors.lastname: Sims
authors.affiliation: Primary Care Clinical Sciences, NIHR School for Primary Care Research, University of Birmingham, Birmingham, West Midlands, UK.
authors.forename: Satinder
authors.initials: S
authors.lastname: Singh
authors.affiliation: West Midlands Ambulance Service NHS Trust, Regional Ambulance Headquarters, Dudley, West Midlands, UK.
authors.forename: Matthew
authors.initials: M
authors.lastname: Ward
authors.affiliation: Department of Primary Care Health Sciences, NIHR School for Primary Care Research, University of Oxford, Oxford, Oxfordshire, UK.
authors.forename: Richard J
authors.initials: RJ
authors.lastname: McManus
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D004631:Emergency Medical Service Communication Systems; D004632:Emergency Medical Services / Q000379:methods*; D004636:Emergency Service, Hospital / Q000458:organization & administration; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009460:Neurologic Examination / Q000379:methods; D020521:Stroke / Q000175:diagnosis / Q000628:therapy*; D013997:Time Factors
keywords: emergency ambulance systems, effectiveness; epidemiology; imaging, CT/MRI; paramedics, clinical management; stroke